1. Please complete the questions below to assess your facility's disaster readiness.

* 1. Please select your type of organization. You may select more than one.

* 2. In the past year, has your facility/organization communicated with your local emergency management agency?

* 3. Do you know about your local government’s emergency or disaster plan for your community?

* 4. Do you know how to find the emergency broadcasting channel on the radio or television?

* 5. In the past six months, has your facility/organization provided education to patients on disaster preparedness?

* 6. In the past six months, has your facility/organization provided education to staff on disaster preparedness?

* 7. In the past six months, has your facility/organization reviewed and updated the disaster plans?

* 8. In the last year, has your organization made a specific plan for how you and your staff would communicate with each other and with patients during an emergency situation?

* 9. In the last year, have your facility’s/organization’s staff practiced in or drilled on what to do in an emergency in the facility?

* 10. In the last year, has your facility/organization encouraged patients and staff to prepare a Disaster Supply Kit with emergency supplies like water, food and medicine that is kept in a designated place at home?

* 11. In the last year, has your facility/organization encouraged your patients and staff to prepare a small kit with emergency supplies that you keep at home, in your car or where you work to take with you if you had to leave quickly?

* 12. Optional Contact Information

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